AHLA's Speaking of Health Law

Addressing Provider Professionalism Concerns, Part 1

October 12, 2021 AHLA Podcasts
AHLA's Speaking of Health Law
Addressing Provider Professionalism Concerns, Part 1
Show Notes Transcript

How can medical staff leaders address concerns around provider professionalism? Sharon Beckwith, CEO, MDReview, speaks with Don Lefkowits, MD, FACEP, physician at Denver Health and current president of the Colorado Medical Board, and Sara Cameron, CPMSM, CPCS, Director of Medical Staff Services at Hospital Sisters Health System, about some of the challenges posed by provider professionalism concerns and strategies that the medical staff office can take to handle these delicate situations. They discuss how to track provider professionalism concerns, the key components of professional conduct policies as well as effective use of such policies, and how to enforce employment protections against retaliation when a complaint is made. Sponsored by MDReview.

Listen to Part 2, where the panelists discuss the steps that medical staff professionals should take when addressing concerns over provider behavior and creating a culture of accountability. 

To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.

Speaker 1:

Support for A H L A comes from MD review, which provides exceptional external peer review and consulting solutions. They focus on integrity, objectivity, confidentiality, and timeliness to provide clients with an incomparable resource. For 20 years, MD Review has helped leading healthcare entities address key strategic challenges related to medical staff services, credentialing, quality, risk management, peer review, and compliance. For information, visit md review.com.

Speaker 2:

Well, thanks so much for joining us today. We really appreciate it. My name is Sharon Beckwith. I'm the c e O of MD review, and really excited to, uh, be able to talk with you all today, um, with two of my colleagues. I'm Dr. Don Leitz is an emergency medicine physician by training. Uh, worked here in the Denver area in emergency medicine for 40 years and now is currently a physician at Denver Health doing adult urgent care. And he is the current, um, board president of the Colorado Medical Board. I'm also honored to have Sarah Cameron here with us today. Sarah Cameron is an M S P. She is a dual certified, um, M S P by nams. She's on the NAMS board. She's a director at large, and she is the current, uh, director of Medical Staff services at Hospital Sisters Health System in Illinois. So today we're gonna talk to you about provider professionalism, provider behavior, um, and just talking about some of the challenges that we have. What is it, um, how do we address it and what are the challenges as a medical staff, as a medical staff leader and as a medical staff professional, um, in the medical staff office. How, you know, how can we address it effectively? Um, and what are some of the challenges that we run up against? So, um, I know we see it sometimes in peer review and external peer review. Um, oftentimes, um, we find ourselves in the position where a facility may try to utilize external peer review to address a physician behavior issue, which really is not the right form for that. Um, and so we're gonna talk with you all today just about what is the right way to go about it and how can we address it effectively. So Dawn and Sarah, let's, let's open it up.

Speaker 3:

Thanks Sharon. Uh, and, and welcome everybody. Um, so I always, I always like to start with a little story. Sharon smiling already. I, uh, but, um, so I started practicing in the Denver area, uh, in a busy urban ER back in 1980. And it was, I learned pretty quickly that it was pretty much assumed that every hospital had a couple of providers who were critical to the profitability of the hospital. Uh, who, um, but also you had a sort of wink, wink, nod, nod and ignore behavior that by today's standards would be completely unacceptable. Uh, and we in particular, we had one surgeon, uh, I'll call him John, um, that was actually his first name. I won't mention his last name. Um, and he was known as a yeller cursor thrower. And on top of that behavior, um, had some boundary issues, but he was also thought of as a really skilled technical surgeon. And he was very productive. So the c e o liked having him on staff, and people were expected to just look the other way. And nursing staff was expected to look the other way. Other colleagues were expected to look the other way. Uh, it was always like, well, if, you know, if you're in a pinch, you really need, uh, a, an emergency surgery. That's who you want in the or. And it didn't take very long for me. I was sort of young, fresh outta medical school, but in residency. But it, it, it, it was became pretty clear that, that although the goal was to look the other way, the effect it had on, uh, the culture of the hospital was quite pervasive. And, uh, nursing staff didn't wanna work with them. They practiced out of fear. Uh, colleagues were sometimes resentful that his behavior was tolerated. Um, and so the, the purpose of telling the story is why does it matter? Why do we even talk about professionalism, collegiality and, and appropriate collegial respectful behavior? And it's important to recognize that if unprofessional conduct boundary violations, confrontational kind of behavior is left unchecked by medical staff leadership or hospital leadership, it can affect patient safety. It clearly can affect the morale of providers and nursing staff and any other ancillary staff with whom that particular provider comes into contact with. Uh, it certainly can have an effect on patient satisfaction in the overall patient experience. Uh, it has an effect, an adverse effect on, on the culture of the facility. It actually can present challenges, uh, in, in both provider recruitment and retention. And I would have to say, uh, you know, based on the current environment dealing with the pandemic burnout, the stress like we've never seen before on our providers being able to create a supportive collegial and mutually respect professional environment encourages providers to stay, to be satisfied with their work, to get emotional and professional satisfaction from their work because the support of their colleagues is what actually keeps them going. And I think that's true probably now more than ever. So, setting the stage, I, I want to turn it over to Sarah cuz I know she has, has the medical staff professional's perspective because, uh, she has to deal with these, uh, the, the outliers. Um, uh, but that was, you know, sort of my attempt at setting the stage for why does it even matter and why are we even talking about it?

Speaker 4:

Uh, I appreciate that Dr. Lefkowitz. And just to add to that, I mean, this isn't a new concept. Joint Commission came out in 2008 with a Sentinel event alert that said that, um, behaviors that undermine a culture of safety are detrimental to patient care. So th this is not a new concept, but yeah, I have, um, my mom's an emergency room nurse and she says the things that we discuss now in address from physician behavior perspectives, they were just tolerated back in a different time period. And I, I, I think that's, you know, for lots of reasons, I think people are more acutely aware of how they react to things and how they feel. And, um, and we really do see a correlation between a surgeon and an OR who's upset with the OR staff, he puts that or staff on edge, and they're more likely to miss things during that surgery. So, um, you know, I always hear, well, yeah, he's a little gruff with staff, but he's so good with his patients and it's like one does not dismiss, the other one does not make up for the other. You have to be collegial to everyone involved or the captain of the ship. You set the tone of every procedure and, um, patient contact. So it's, it's more than just, um, you know, a problem. It really does have an impact on patient care. And, you know, I think it takes a team approach to fix it. I think a lot of things can be addressed in the moment. A physician who turns around after a procedure and addresses it with the staff and says, I lost my cool, I was really panicked about X, Y, Z. Um, that can diffuse the situation and, you know, really bring some trust building to the team. But a provider who has a consistent pattern of disruptive behavior, it's not just this one-off one time thing that happened. Um, that's what we need to worry about because they are driving a culture where people don't wanna work on that case. So you get the less, um, maybe experienced staff members there, you get the, uh, it just creates so many dynamics that impact patient care. And that's why this is so important.

Speaker 3:

Um, Sarah, you're bringing up a good point, uh, about, uh, tracking repetitive behavior. Yes. What, what's the medical staff professionals' role in, in making sure, you know, the, the medical staff leadership often turns over. There may be a lack of historical perspective and, and, uh, institutional memory. Uh, and that often lives in the medical staff office. Mm-hmm.<affirmative>. Um, h how do you, how do you make sure that, uh, providers who have a track record of issues, uh, you know, are are monitored and tracked in a way that new, new co incoming medical staff leadership are aware of what the historical perspective is?

Speaker 4:

Absolutely. So I talked to Sharon a lot about this. We have a mechanism that we put in place where, um, o obviously events can come, come in from various, um, directions. We get emails letting us know there was a disruption. We get, um, event reports entered into the event system that we have to address. We capture all of those in a tracking mechanism within the med staff office. That's part of our database and credentialing file. But I think the important thing that we put in place in the last few years, that has made a huge difference because as you say, medical staff leaders turn over so frequently. Yeah. Um, the people who just, as soon as they're getting seasoned at having a collegial intervention or, or a conversation, it seems like they're out of that role and we're training someone else how to do it. Um, but we re we track all of them. So even if we have a behavior that comes in that we deem really not worthy of addressing, because it's kind of a nuisance thing, you know, people weaponize our event reporting system. We know that, um, we record those all onto a spreadsheet for each provider. So when you get an event that comes in and I need to send it to your medical staff leader to, um, discuss next steps, I send them a little snippet that shows every single disruptive behavior event that they have had, or professionalism event that they have had in their entire time with the organization. And what that does is it enables me to email that department chair or medical director and say, you know, Dr. Lefkowitz, he, um, screamed at a nurse on the floor today, and here's a list of the five other times in the last five years that that has happened. And the, the, what we did to address those things. So that way our medical staff leader, first of all, has a quick glimpse right away and says, well, we've had four collegial conversations with Dr. Lefkowitz. Maybe we need to pull in some additional members of the medical staff to sit down with him and express the seriousness of this. Maybe he needs to come and speak with M E C, but it lets that department chair know right up front what the track record is and if there's a trend or pattern to some of these events. Keeping that has actually shown us. We had an ER physician who he would go great for a long time and then it would just explode with all these patient complaints and nursing complaints. And we looked back at the schedule, well, those explosions all seemed to happen when he was taking on extra shifts. So that was a quick and easy way for us to communicate to the medical director. Like, look, he, when you give him all this, these extra hours, he can't manage his own, um, stress very well. And it, it's showing in his patient interactions and staff interactions. So there's a lot of benefit to tracking all of these professionalism issues. Also have a code of conduct. You have to have a code of conduct that every provider signs off on that holds them accountable to, um, the expectations of professionalism. And then have a professionalism policy that guides that medical director or, um, department chair or medical staff president to say, okay, at the third instance of a professionalism issue, you're gonna meet with the provider, with the medical staff president, and with the C M O at a fourth event, the provider must come and meet with me. C. So if you delineate those actions and you use them consistently across the board, when you have a validated concern, the process becomes very easy to follow. Cuz it's going to be the same each time, oh, it's the third one in 24 months, we're doing this action next. So those are just a couple of the ways that I help guide our medical staff leaders to be able to address their, um, professionalism concerns that come forward for their, the members of their department.

Speaker 3:

Sure.

Speaker 2:

And Sarah, when do you share that code of conduct and that professionalism policy? Is it something that's just given to a provider when they first come on staff and then that's it? Is it something that's shared with them repetitively?

Speaker 4:

Yep. We have them, um, sign it with their initial application before they come on staff. Then at their orientation where they come in and we do the verification of ID and all the things that have to be done in person E M R training, um, we give it to them again and have them sign it again. So they get it at orientation and initial. And then every year at reappointment, it's one of the required documents that they have a reminder of the code of conduct. And then of course, if we sit down and meet with you to talk about your conduct, we're gonna give it to you again and have you sign it again. So we make sure that they're constantly being reminded that part of being a member of that medical staff is that there is a code of conduct that you've agreed to follow.

Speaker 3:

Yeah. Uh, you know, I I think that's a great point. Um, you know, one of the other, um, players in all this are, uh, malpractice carriers and, um, they, they cringe at, uh, disruptive behavior because they recognize not only does it compromise patient safety and increase risk, uh, uh, but it also, uh, can contribute to adverse outcomes. Uh, because as, as you mentioned, uh, staff are much less likely to speak up when they have a concern about how a procedure's going. Um, you know, or, or something like that. And, uh, you know, it's, it, it's clear that, you know, this is, this is critical to lowering malpractice risk by being collegial and supportive of your colleagues. You know, the the other thing that comes to mind when, when we're talking about interventions and the, the importance of tracking, you know, one of the other things that I think, uh, when it, when it comes to boundary issues, uh, professional, unprofessional conduct, um, it's easier to keep somebody off your medical staff than it is to take action to remove them once they've been fully, uh, privileged and credentialed. And so, one of the other things that I, in my years as, uh, chair of the credentials committee, when we'd have, uh, providers applying for new, uh, privileges new to the hospital, uh, staff, um, I, if there was any red flag at all in their past history, uh, regarding potential conflicts with other providers or nursing staff complaints, even perhaps, uh, you know, a letter of recommendation that has that little bit of a red flag that just catches your attention. Um, you know, rather than, you know, if they've, if they meet the basic criteria of board certification and maintenance of, uh, of, uh, competency and those sorts of things, if there are concerns about behavioral issues, we would always, uh, um, require an in-person interview. Uh, usually two, one with the chair of the credentials committee and one with the department chair of whatever department that, uh, provider might be entering. Uh, and it wouldn't just be a 10 minute, Hey, how you doing? Nice to meet you. Welcome to the medical staff. Uh, it, it would be a, a pretty detailed, uh, um, you know, interview. And oftentimes if there were continuing concerns, we'd ask for additional letter letters of recommendation. We would make direct contact with the previous department chair to see if we could learn about, uh, what, what the details were of, of previous behavioral issues. And if we got the sense that we were tapping into something that was gonna be an ongoing concern, uh, we might, uh, withhold credentials and privileging if we felt like we had legal ground to do so. Or we, we would, as you say, um, review in detail the code of conduct, you know, and, and sort of, uh, do a, we're gonna be watching very, very carefully because we value, uh, a high level of collegiality and professionalism with, uh, amongst our medical staff. And if we think you're posing a threat to that, we're gonna take action early and definitively to make sure that you don't disrupt that culture that we've tried to develop.

Speaker 4:

Right.

Speaker 3:

I don't know if you've run into that with your experience.

Speaker 4:

Yeah, absolutely. If we have a applicant who comes through the credentials process who has an identified professionalism issue, we absolutely, that orientation takes place. And then they have a scheduled 30 minute with our, um, C M O president of the medical staff and their department chair, and they lay it out. They say, this is how we track it. This is what, this is our progressive approach to dealing with disruptive behavior. We talk about our strong culture of safety in the organization and that, you know, we have a zero tolerance for any form of, um, disruptive behavior that can impact patient care. So we do pretty much the exact same thing. We do grant the privileges unless we have grounds to not grant the privileges, but this not come in and practice until they've had orientation and have that meeting with our, um, department chair. I will also tell you my credentialing team is very good about giving myself and the C M O or the department chair's heads up because we talk to these guys on the front end before they come in, they're filling out paperwork. They, um, if they are rude to us, if they are difficult in any way, my team's the first ones to say, you know, how he treats this, what they view as just a credential and an office pushing paper is very indicative of how they will treat staff. And we take that very seriously. So often a provider will come in, they don't have any red flags about behavior, but the C M O will say, so my team shared with me this email that you sent, and I wanna point out that this is the kind of thing that we do not tolerate at this organization. We respect one another, and I really appreciate that about my C M O and our organization is they don't just go, okay, okay, it's a doctor being rude to a paper pusher,<laugh>. No. They say that that's, um, a sign, that's a sign. There's problem and they take it very seriously. But if you're not proactive, you know, you're having a huge opportunity to control that happening within your organization. I will tell you, the ones that we've had the proactive conversations with haven't really had any issues. Cause they just know there's gonna be a consequence for this. The old days are gone.

Speaker 3:

Yeah. You make it clear going in, uh, what the expectations are. And, and I think most people can rise to the occasion and, and you make a good point when, when they think nobody's watching, sometimes that behavior comes through. And, and that's probably indicative of, of what's gonna happen, uh, long term. One of the other things, uh, Sarah, I, I was curious about, I I, I know one of the problems that I've run into in my years as, uh, as a department chair, uh, when issues would happen, I is reluctance on the part of nursing staff in particular, sometimes other ancillary services and, and sometimes, you know, uh, PAs or nurse practitioners or maybe even a colleague, there's a reluctance to, to report formally or even informally, um, when you've been witness to, uh, you know, an event of some kind, whether it's a patient interaction or a interaction with family or with staff that just made you feel uncomfortable. And, um, what, you know, what are there, uh, in the way of, from an employment, uh, uh, standpoint, um, you know, protections against retaliation. And so that, you know, you, one of the ways to help create this kind of culture that we're talking about is to make sure that staff are comfortable saying, Hey, that I'm not okay with this. I need to let somebody know. Yep. Um, how, how does that work within the hospital employment

Speaker 4:

Structure? Yeah. To share that. I experienced a lot of that of staff saying, oh yeah, that did happen, but I don't wanna go on record as a witness, or I don't wanna make a formal complaint or, um, and I found that was largely because of the fear of retaliation and I'm not talking, okay, doc finds out that you filed this complaint and goes and slashes your tires. It's a subtle, passive aggressive mm-hmm.<affirmative>, um, you know, almost subtle bullying that takes place when some providers find out that a report's been made about them. There are a couple ways we address that. One, all of our policies around professionalism, code of conduct, peer review, include language about retaliation and that there's a zero tolerance for retaliation. Um, we have suspended people for up to 30 days for retaliatory behavior. Um, but one of the things that when I came in, I had to do was I had to tell my C M O stop going and talking to them as soon as you get the event report stop. Because as soon as you go talk to them and tell them there's an event and we haven't talked to the complainant, we haven't, you know, validated the concern that provider now knows and he's gonna run right to a nursing station, right to the OR desk and he's gonna wanna talk about it with that person. And that is, that's not protecting the person who made the complaint. Yeah, for sure. So, um, that was one of our first actions. I said, no one is to go and address with the provider until it's been reviewed and we've formulated a game plan for addressing this. So that was number one. Number two was just years of working with the staff, um, who handled patient complaints and the staff that might have had an interaction with the physician to create that sense that we will address these things cuz that's why nobody wants to report it. I, people would report it all day if they thought that every time they reported something it would get addressed and it would get resolved. And the big turning point for us was when you enter an event report, you get that automated response, thank you for entering your event. We'll take care of it. You probably won't hear back from us. When I get those reports, I now personally as the director of med staff send an email to whoever put that complaint in. If they were not anonymous and I tell them, I have received this, I'm reviewing this within our policies, we will be speaking with the provider and following the steps that are delineated in our policy. If this provider has any discussions with you at all about this event, you need to immediately let me know. And those people who are making those complaints have started to see movement on addressing the concerns because now that people are reporting, we have trending, we have tracking, we don't have one massive event, which isn't always enough to take action on a provider. We can talk to'em about it, but then we find out there were 10 previous events that no one reported. Well, when you sit down with a provider with one event versus a pattern of 10 events, it's a very different conversation and behaviors start to change. But when you wait till that one big event, then the provider claims retaliation by the staff. The provider claims, you know, this was just a one-time thing, I lost my goal. But if you get people to start reporting and have confidence in the reporting that it is being addressed, they're hearing someone say to them, look, I I'm gonna protect you in this. I will hide your name, but the provider will probably know that it was you because there aren't that many people. But here's the steps we're gonna follow. I can't tell you what the final outcome is, but here's our policy that we follow, know that we're gonna follow that policy. It's about building that confidence with the teams that you are actually addressing things. There's this big mystique that administration blows over behavior stuff. If a provider is very lucrative and it's about taking administration out of it and making it a med staff issue that's handled by their peers who are medical staff leaders, that is key to addressing behaviors. Stop having your admin people involved in those conversations cuz then it's an us against them. Whereas if you have their peers meet with them, talk about it, say we get it, we get that the or has problems with their circulators, but you can't lose your cool cuz this is what happens. It's those kinds of conversations that are more effective than the suits coming in to address it. And I, I unfortunately believe that nursing staff and staff in the hospital really believe that administration doesn't care so much about behaviors because of the money that comes in. And that's not true. They just don't really have the tools to take care of it like we do in med staff services.

Speaker 3:

And

Speaker 2:

That's a big cultural change that you're talking about. And that's something that definitely takes time, right? You implement and really what you're talking about is people now feel like they're being heard, they're being heard and they're being listened to and it's being followed through one. But definitely that's something to sort of shift the ship of culture. Um, that's a big change and it definitely takes time and it's a commitment from all of you, um, in your medical staff, your medical staff leadership to really stay with it. Um, and to be able to implement that, that change.

Speaker 3:

You brought up a very important, uh, point Sarah. Uh, it, it really does need to be a medical staff. You know, you, you have a, an an independent medical staff of credentialed providers and the expectations for behavior, for consequences of, uh, bad behavior, uh, have to be, uh, handled at the medical staff level by medical staff leaders. And, uh, it's not, there really isn't a role for administration. Uh, and you know, that e even if the, maybe they give the impression that, well administration doesn't really care cuz it's a high, high volume provider, but, uh, the message to the support staff should be, um, no, your medical staff leaders are the ones who are gonna handle this because that's where it should be handled.

Speaker 4:

Yeah, for sure. Um, I think it, it has been a huge game changer to remove the CMOs from the process of addressing behaviors. Um, and it, it wasn't an easy one. It's hard to convince a chief medical officer or a VP m a to, um, you know, please don't address these behaviors. I know that your instinct is to in the moment, go talk to the provider, get it resolved, tell'em that they can't do it again. But that's not really, it doesn't, we, I don't show results from following that process. So, um, really moving those CMOs out of that conversation using a graduated approach where they meet with many members of their peer group from the medical staff leadership team, and then maybe bringing in administration when you wanna, you know, make it concrete with the provider that this is really a concern for us. Then you bring in administration, but the decisions need to be made by the elected medical staff members. Um, it's really important that, um, the people who, whose behavior you are addressing don't think that this is a, you know, corporate versus medical staff and exactly. They'll, they'll convince themselves, oh, they just want me out of here. Or Oh, they don't, you know, I'm, I'm dealing with the C M O about surgery times and block times and this is kind of, of retaliation for that. They will make a lot of connections. The other thing that's really beneficial is when I bring a provider in and I'm with the medical staff president and I'm with their department chair and we're having a conversation about some patterns of behavior and they go, well, you know, I've been trying to tell that or staff that director for years that this is the right protocol and I will stop the conversation and I'll say, that is really important to us and that really needs to be addressed. And you need to schedule some time to sit down and talk to the CMO about that. He can help you remove those barriers. We're here to talk about your behavior, right? Not about the things that are triggering your behavior, the behavior's inappropriate. No matter what the trigger you should, you should address the trigger. But we're here to talk about you and your reactions.

Speaker 3:

You, you mean you've seen physicians deflect responsibility for their own behavior onto some other area? Uh, I've never seen it. I every time go figure<laugh>.

Speaker 4:

Yeah. So I, I think that there's a lot of things you can change culturally to make your professionalism addressing professionalism easier and more effective. And then there's a lot of things that just need done about your processes and your steps and educating people on how to have those crucial conversations. Picking the right people to be in the room. I have some department chairs who they're abysmal at doing a, a, uh, collegial intervention. They're just so sympathetic to the provider and um, and it's like, oh, that puts me in the position to them be a bad cop and I'm not a peer. So<laugh>, you know, really exactly. Take your people. We sometimes sit at me C and go, okay, this has gotten to the level they need to talk to several of us. And we look around the room and go, oh yeah, that one Chris should do it. Capric should do it<laugh>. So I mean, you know, the people who are good at it and effective at it and um, you know, being very prepared for that conversation. Have a pre-meeting with the people who are gonna be there and say, okay, here's the key points we need to make sure we hit. Here's the things that, um, we need to set expectations. We need to describe what, what will happen if those expectations aren't met. Um, have that pre-meeting. Be completely ready for what you're gonna say before that provider gets in the room. Let them have their time to talk for 10, 15 minutes and then say, okay, so here's some questions we have for you. Would you have done it differently? You know, start with that every time. Cuz that opens their mind to you. Well, would I have done it differently? And then you can open the conversation.

Speaker 2:

A lot of what I've heard today is, you know, there are, everybody has different resources right? Within their medical staff. And like you said, Sarah, there are, um, some physicians that are really good at having, um, critical conversations and are really good natural physician leaders. And I think Dr. Leitz, you've seen it in your career, right? There are just some physicians that naturally have a really good ability to be a leader and others that really struggle with it. And so I think it's always helpful to, um, you know, again, provide the training and the tools that those physician leaders need, but you also have to, um, utilize those that have a natural ability and utilize the resources that you have. Um, and it also just shows to me, you know, a lot of what we're talking about is just the importance of everything from initial credentialing and bringing a provider on board and really having a very strong medical staff office and having a really, uh, you know, experienced medical staff professional like yourself, Sarah, who can train a team to really have that spidey sense right. And have that gut feel of, ooh, we're going down the wrong path with somebody here, or we really need to do something about it. Because like you said at the beginning, Dr. Lefkowitz, it's so much easier to not bring somebody on staff who's going to create problems for you than it is to try to get rid of them Sure. Once they're on your medical staff. And so, you know, just so much what we're talking about, it's, it's just utilizing your resources that you have, but also really having a very strong medical staff office I think, um, is so important for all of this. So I think what we'll do is we'll wrap it up and then we've got a second session where we're gonna be able to talk with everybody more just about now we know what the problem is now what do we do about it and how do we address it. Great. Thank you.

Speaker 1:

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